Hymenal Laceration

The hymen must be examined in detail after an allegation of a nonconsensual penetrative act. When the hymen is fimbriated, this assessment may be facilitated by the gentle use of a moistened swab to visualize the hymenal edges. When the hymenal opening cannot be seen at all, application of a few drops of warm sterile water or saline onto the hymen will often reveal the hymenal edges. Foley catheters are also a useful tool to aid hymenal visualization in postpubertal females (138). A small catheter is inserted through the hymenal opening, the balloon is then inflated with 10-20 mL of air, and the catheter is gently withdrawn so that the inflated balloon abuts the hymen. The balloon is deflated before removal. This procedure is well tolerated by the examinee. Obviously, in the acute setting, none of these maneuvers should be attempted until the relevant forensic samples have been retrieved.

There is little specific information available regarding the type and frequency of acute hymenal injuries after consensual sexual acts, particularly regarding the first act of sexual intercourse. Slaughter et al. (90) conducted colposcopic examinations of the genitalia of 75 women who had experienced "consensual" vaginal intercourse in the preceding 24 hours. They found lacerations (tears) with associated bruising at the 3-o'clock and 9-o'clock positions on the hymen of a 14-year-old and bruises at the 6-o'clock and 7-o'clock positions on the hymens of two other females (aged 13 and 33 years). No other hymenal injuries were detected. Unfortunately, no details regarding previous sexual experience are recorded on their pro forma.

In the same article, the hymen was noted to be one of the four most commonly injured genital sites among 311 postpubertal complainants of nonconsensual sexual acts. The hymenal injuries detected colposcopically were bruises (n = 28), lacerations (n = 22), abrasions (n = 13), swelling (n = 10), and redness (n = 4). The hymenal lacerations were either single (n = 12), nine of which were at the 6-o'clock position, or paired around the 6-o'clock position (n = 10). The authors found that hymenal lacerations were four times more common in the younger age groups. Again, there was no information regarding previous sexual experience. Bowyer and Dalton (133) described three women with hymenal lacerations (detected with the naked eye) among 83 complainants of rape who were examined within 11 days of the incident; two of the three women had not previously experienced sexual intercourse. One retrospective survey of the acute injuries noted among adolescent complainants of sexual assault (aged 14-19 years) found that hymenal tears were uncommon, even among the subgroup that denied previous sexual activity (132). Bruises, abrasions, reddening, and swelling completely disappear within a few days or weeks of the trauma (90,139). Conversely, complete hymenal lacerations do not reunite and thus will always remain apparent as partial or complete transections (123), although they may be partially concealed by the effects of estrogenization (140). However, lacerations that do not extend through both mucosal surfaces may heal completely (2). There is one case report of a 5-year-old who was subjected to penile penetration and acquired an imperforate hymen resulting from obliterative scarring (141).

On the basis of the current literature, complete transections in the lower margin of the hymen are considered to provide confirmatory evidence of previous penetration of the hymen. However, it is not possible to determine whether it was a penis, finger, or other object that caused the injury, and there is an urgent need for comprehensive research to determine whether sporting activities or tampon use can affect hymenal configuration. Although partial or complete transections of the upper hymen may represent healed partial or complete lacerations beyond the acute stage, there is no method of distinguishing them from naturally occurring anatomical variations.

Goodyear and Laidlaw (142) conclude that, "it is unlikely that a normal-looking hymen that is less than 10 mm in diameter, even in the case of an elastic hymen, has previously accommodated full penetration of an adult finger, let alone a penis." However, there is no objective evidence on which to base this conjecture, and it is not known whether measuring the hymenal open ing using a digit, or other previously measured object, in the clinical setting when the practitioner is particularly anxious not to cause the patient any distress accurately reflects what the hymen could have accommodated during a sexual assault.

On the other hand, it is now generally accepted that postpubertal females can experience penile vaginal penetration without sustaining any hymenal deficits; this is attributed to hymenal elasticity (142,143). Furthermore, the similarity between the dimensions of the hymenal opening among sexually active and nonsexually active postpubertal females (96) makes it impossible for the physician to state categorically that a person has ever had prior sexual intercourse unless there is other supportive evidence (pregnancy, spermatozoa on a high vaginal swab; see Subheading 8.5.; Forensic Evidence) (96,142,144).

Lacerations and ruptures (full-thickness lacerations) of the vagina have been described in the medical literature after consensual sexual acts (145147). They are most commonly located in the right fornix or extending across the posterior fornix; this configuration is attributed to the normal vaginal asymmetry whereby the cervix lies toward the left fornix, causing the penis to enter the right fornix during vaginal penetration (147). Factors that predispose to such injuries include previous vaginal surgery, pregnancy, and the puerperium, postmenopause, intoxication of the female, first act of sexual intercourse, and congenital genital abnormalities (e.g., septate vagina) (145). Although most vaginal lacerations are associated with penile penetration, they have also been documented after brachiovaginal intercourse ("fisting") (147), vaginal instrumentation during the process of a medical assessment (147), and the use of plastic tampon inserters (148).

Vaginal lacerations have been documented without any direct intravaginal trauma after a fall or a sudden increase of intra-abdominal pressure (e.g., lifting a heavy object) (147).

Injuries of the vagina have been noted during the examinations of complainants of sexual assault. Slaughter et al. (90) describe 26 colposcopically detected vaginal injuries among the 213 complainants who had genital trauma identified. These were described as "tears" (n = 10), bruises (n = 12), and abrasions (n = 4). Other articles that considered only macroscopically detectable lesions found vaginal "injuries" in 2-16% of complainants of noncon-sensual penile vaginal penetration (133,134). However, one study included "redness" as a vaginal injury when, in fact, this is a nonspecific finding with numerous causes.

When a vaginal laceration may have been caused by an object that has the potential to fragment or splinter, a careful search should be made for foreign bodies in the wound (145) (this may necessitate a general anesthetic), and X-rays should be taken of the pelvis (anteroposterior and lateral), including the vagina, to help localize foreign particles (149). Any retrieved foreign bodies should be appropriately packaged and submitted for forensic analysis.

Bruises and lacerations of the cervix have been described as infrequent findings after nonconsensual sexual acts (90,150,151). In one article, the injuries related to penetration by a digit and by a "knife-like" object. There are no reports of cervical trauma after consensual sexual acts.

8.6.2.5. Nonspecific

Norvell et al. (126) have also documented areas of increased vascularity/ telangiectasia (n = 7), broken blood vessels (n = 2), and microabrasions (n = 2) during colposcopic assessment of the introitus, hymen, and lower 2 cm of the vagina of 18 volunteers who had participated in consensual sexual activity within the preceding 6 hours. However, the areas of increased vascularity may have been normal variants (90), and the precise location of the other findings was not described. Fraser et al. (152) describe the macroscopic and colposcopic variations in epithelial surface of the vagina and cervix in healthy, sexually active women (age 18-35 years). They documented changes in the epithelial surface in 56 (17.8%) of the 314 inspections undertaken; six were located at the introitus, 26 in the middle or lower thirds of the vagina, eight on the fornical surfaces of the cervix, 14 in the vaginal fornices, and two involved generalized changes of the vaginal wall. The most common condition noted was petechiae. The more significant conditions noted were three microulcerations, two bruises, five abrasions, and one mucosal tear. The incidence of these conditions was highest when the inspections followed intercourse in the previous 24 hours or tampon use.

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.